Provider Demographics
NPI:1881942779
Name:LEGACY HEALTH MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:LEGACY HEALTH MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNIT
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-644-1540
Mailing Address - Street 1:3500 OAK MANOR LN # 46
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-1211
Mailing Address - Country:US
Mailing Address - Phone:727-489-3305
Mailing Address - Fax:727-499-9559
Practice Address - Street 1:3500 OAK MANOR LN # 46
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-1211
Practice Address - Country:US
Practice Address - Phone:727-489-3305
Practice Address - Fax:727-499-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105069207R00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME105069OtherMEDICAL LICENSE NUMBER